What is Major Depression?

Major depression is a serious medical illness affecting 9.9 million American adults, or approximately 5 percent of the adult population in a given year. Unlike normal emotional experiences of sadness, loss, or passing mood states, major depression is persistent and can significantly interfere with an individual’s thoughts, behavior, mood, activity, and physical health. Among all medical illnesses, major depression is the leading cause of disability in the U.S. and many other developed countries.

More than twice as many women (6.7 million) as men (3.2 million) suffer from major depressive disorder each year. Major depression can occur at any age including childhood, the teenage years and adulthood. All ethnic, racial and socioeconomic groups suffer from depression. About three-fourths of those who experience a first episode of depression will have at least one other episode in their lives. Some individuals may have several episodes in the course of a year. If untreated, episodes commonly last anywhere from six months to a year. Left untreated, depression can lead to suicide.

Major depression, also known as clinical depression or unipolar depression, is only one type of depressive disorder. Other depressive disorders include dysthymia (chronic, less severe depression) and bipolar depression (the depressed phase of bipolar disorder or manic depression). People who have bipolar disorder experience both depression and mania. Mania involves abnormally and persistently elevated mood or irritability, elevated self-esteem, and excessive energy, thoughts, and talking.

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What are the Symptoms of Major Depression?

The onset of the first episode of major depression may not be obvious if it is gradual or mild. The symptoms of major depression characteristically represent a significant change from how a person functioned before the illness. The symptoms of depression include:

  • persistently sad or irritable mood
  • pronounced changes in sleep, appetite, and energy
  • difficulty thinking, concentrating, and remembering
  • physical slowing or agitation
  • lack of interest in or pleasure from activities that were once enjoyed
  • feelings of guilt, worthlessness, hopelessness, and emptiness
  • recurrent thoughts of death or suicide
  • persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain

When several of these symptoms of depressive disorder occur at the same time, last longer than two weeks, and interfere with ordinary functioning, professional treatment is needed.

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What are the Causes of Major Depression?

There is no single cause of major depression. Psychological, biological, and environmental factors may all contribute to its development. Whatever the specific causes of depression, scientific research has firmly established that major depression is a biological brain disorder.

Norepinephrine, serotonin, and dopamine are three neurotransmitters (chemical messengers that transmit electrical signals between brain cells) thought to be involved with major depression. Scientists believe that if there is a chemical imbalance in these neurotransmitters, then clinical states of depression result. Antidepressant medications work by increasing the availability of neurotransmitters or by changing the sensitivity of the receptors for these chemical messengers.

Scientists have also found evidence of a genetic predisposition to major depression. There is an increased risk for developing depression when there is a family history of the illness. Not everyone with a genetic predisposition develops depression, but some people probably have a biological make-up that leaves them particularly vulnerable to developing depression. Life events, such as the death of a loved one, a major loss or change, chronic stress, and alcohol and drug abuse, may trigger episodes of depression. Some illnesses such as heart disease and cancer and some medications may also trigger depressive episodes. It is also important to note that many depressive episodes occur spontaneously and are not triggered by a life crisis, physical illness, or other risks.

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How is Major Depression Treated?

Although major depression can be a devastating illness, it is highly treatable. Between 80 and 90 percent of those suffering from serious depression can be effectively treated and return to their normal daily activities and feelings. Many types of treatment are available, and the type chosen depends on the individual and the severity and patterns of his or her illness. There are three basic types of treatment for depression: medications, psychotherapy, and electroconvulsive therapy (ECT). They may be used singly or in combination.

  • MEDICATION The first antidepressant medications were introduced in the 1950s. Research has shown that imbalances in neurotransmitters like serotonin, dopamine, and norepinephrine can be corrected with antidepressants. Four groups of antidepressant medications are most often prescribed for depression:
    • Tricyclic antidepressants (TCAs) � still widely used for severe depression. TCAs elevate mood in depressed individuals, re-establish their normal sleep, appetite and energy level, but it often takes three to four weeks for an individual to respond. These medications include amitriptyline (Amititril, Elavil), desipramine (Norpramine), doxepine (Sinequan), imipramine (Antipress, Imavate, Tofranil), nortriptyline (Aventyl, Pamelor), and protriptyline (Vivactyl).
    • Monoamine oxidase inhibitors (MAOIs) � are often effective in individuals who do not respond to other medications or who have “atypical” depressions with marked anxiety, excessive sleeping, irritability, hypochondria, or phobic characteristics. These medications include phenelzine (Nardil) and tranylcypromine sulfate (Parnate).
    • Selective serotonin reuptake inhibitors (SSRIs) � act specifically on the neurotransmitter serotonin. In general SSRIs cause fewer side effects than TCAs and MAOIs. These medications include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa) and escitalopram (Lexapro).
    • Serotonin and norepinephrine reuptake inhibitors (SNRIs) � useful as first-line treatments in people taking an antidepressant for the first time and for people who have not responded to other medications. In general SNRIs cause fewer side effects than TCAs and MAOIs. These medications include Venlafaxine (Effexor)
    • Bupropion (Wellbutrin) � newer antidepressant medication classified as a dopamine reuptake blocking compound. It acts on the neurotransmitters dopamine and norepinephrine. In general bupropion causes fewer side effects than TCAs and MAOIs.

** Consumers and their families must be cautious during the early stages of medication treatment because normal energy levels and the ability to take action often return before mood improves. At this time – when decisions are easier to make, but depression is still severe – the risk of suicide may temporarily increase.

  • PSYCHOTHERAPY There are several types of psychotherapy that have been shown to be effective for depression including cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). Research has shown that mild to moderate depression can often be treated successfully with either of these therapies used alone. However, severe depression appears more likely to respond to a combination of psychotherapy and medication.
    • Cognitive-behavioral therapy (CBT) � helps to change the negative thinking and unsatisfying behavior associated with depression, while teaching people how to unlearn the behavioral patterns that contribute to their illness.
    • Interpersonal therapy (IPT) � focuses on improving troubled personal relationships and on adapting to new life roles that may have been associated with a person’s depression.
  • ELECTROCONVULSIVE THERAPY (ECT) ECT is a highly effective treatment for severe depressive episodes. In situations where medication, psychotherapy, and a combination of the two prove ineffective, or work too slowly to relieve severe symptoms such as psychosis or thoughts of suicide, ECT may be considered. ECT may also be considered for those who for one reason or another cannot take antidepressant medications

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Risk Factors for Suicide

Source: American Foundation for Suicide Prevention

  • Psychiatric Disorders – At least 90 percent of people who kill themselves have a diagnosable and treatable psychiatric illnesses — such as major depression, bipolar depression, or some other depressive illness, including:
    • Schizophrenia
    • Alcohol or drug abuse, particularly when combined with depression
    • Posttraumatic Stress Disorder, or some other anxiety disorder
    • Bulimia or anorexia nervousa
    • Personality disorders especially borderline or antisocial
  • Past History of Attempted Suicide – Between 20 and 50 percent of people who kill themselves had previously attempted suicide. Those who have made serious suicide attempts are at a much higher risk for actually taking their lives.
  • Genetic Predisposition – Family history of suicide, suicide attempts, depression or other psychiatric illness.
  • Neurotransmitters – A clear relationship has been demonstrated between low concentrations of the serotonin metabolite 5-hydroxyindoleactic acid (5-HIAA) in cerebrospinal fluid and an increased incidence of attempted and completed suicide in psychiatric patients.
  • Impulsivity – Impulsive individuals are more apt to act on suicidal impulses.
  • Demographics – Sex: Males are three to five times more likely to commit suicide than females. Age: Elderly Caucasian males have the highest suicide rates.

Suicide Crisis

A suicide crisis is a time-limited occurrence signaling immediate danger of suicide. Suicide risk, be contrast, is a broader term that includes the above factors such as age and sex, psychiatric diagnosis, past suicide attempts, and traits like impulsivity. The signs of crisis are:

  • Precipitating Event – A recent event that is particularly distressing such as loss of loved one or career failure. Sometimes the individuals own behavior precipitates the event: for example, a man’s abusive behavior while drinking causes his wife to leave him.
  • Intense Affective State in Addition to Depression – Desperation (anguish plus urgency regarding need for relief), rage, psychic pain or inner tension, anxiety, guilt, hopelessness, acute sense of abandonment.
  • Changes in Behavior – Speech suggesting the individual is close to suicide. Such speech may be indirect. Be alert to such statements as, “My family would be better off without me.” Sometimes those contemplating suicide talk as if they are saying goodbye or going away.
    • Actions ranging from buying a gun to suddenly putting one’s affairs in order.
    • Deterioration in functioning at work or socially, increasing use of alcohol, other self-destructive behavior, loss of control, rage explosions.

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Warning Signs of Suicide

Source: American Foundation for Suicide Prevention

All of the warning signs of suicide are magnified in importance if the patient is depressed. Although most depressed people are not suicidal, most suicidal people are depressed. Serious depression can be manifested in obvious sadness, but often it is rather expressed as a loss of pleasure or withdrawal from activities that had been enjoyable.

Depression is present if at least five or more of the following symptoms are present during a two-week period; at least one of the symptoms must be either depressed mood or loss of interest or pleasure in usual activities.

  • Depressed mood
  • Loss of interest or pleasure in usual activities
  • Change in appetite or weight
  • Change in sleeping patterns
  • Speaking and/or moving with unusual speed or slowness
  • Loss of interest or pleasure in usual activities
  • Decrease in sexual drive
  • Fatigue or loss of energy
  • Feelings of worthlessness, self-reproach or guilt
  • Diminished ability to think or concentrate, slowed thinking or indecisiveness
  • Thoughts of death, suicide, or wishes to be dead

Suicide can be prevented. While some suicides occur without any outward warning, most do not. Prevent suicide among loved ones by to learning to recognize the signs of someone at risk, taking those signs seriously and knowing how to respond to them. The emotional crises that usually precede suicide are most often both recognizable and treatable. Prevent suicide through early recognition and treatment of depression and other psychiatric illnesses.